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Abstract Objectives Increased cardiovascular risk in rheumatoid arthritis (RA) is well established. Examining traditional cardiovascular risk factors alone underestimates cardiovascular risk in RA. Systematic inflammation, measured by erythrocyte sedimentation rate or C-reactive protein is also a major risk factor. However, the contribution of traditional cardiovascular risk factors (such as obesity and hyperlipidaemia) compared to inflammation is uncertain in psoriatic arthritis (PsA) and RA. We examine the incidence of major adverse cardiac events (MACE) among patients with RA, PsA psoriasis, and controls adjusting for risk factors, inflammation and disease modifying anti-rheumatic drug treatment, to better define cardiovascular risk. Methods Using the Secure Anonymised Information Linkage databank, comprising routinely collected Welsh health data from 1999 to 2013, the incidence and first occurrence of a MACE in individuals with RA (n = 8650), PsA (n = 2128) and psoriasis (n = 24,630) compared to controls (n = 11,87,706) was investigated. Results Traditional cardiovascular risk factors are higher in RA, PsA and psoriasis than controls. After adjusting for these factors, additional cardiovascular risk was only significantly increased in female RA patients (HR = 1.3; 95% CI: 1.0–1.7; p = 0.05) and psoriasis (HR = 1.2; 95% CI: 1.0–1.4; p = 0.02) but not statistically significant for PsA (HR = 1.5; 95% CI: 0.9–2.5; p = 0.13). ESR and CRP were increased in patients with RA but not in patients with psoriasis. Conclusion Additional increased cardiovascular risk was observed in female RA and psoriasis but not PsA. Systematic inflammation is higher in RA but not psoriasis, indicating that there are varying mediators of cardiovascular risk across these conditions. [ABSTRACT FROM AUTHOR]

Purpose To examine the effect of educational attainment in primary school on later adolescent health. Methods Education data attainments at age 7 and 11 were linked with (1) primary and secondary care injury consultation/admissions and (2) the Health Behaviour in School-aged Children survey. Cox regression was carried out to examine if attainment in primary school predicts time to injury in adolescence. Results Pupils that achieve attainment at age 7 but not at age 11 (i.e., declining attainment over time in primary school) are more likely to have an injury during adolescence. These children are also more likely to self-report drinking in adolescence. Conclusions Interventions aimed at children with declining attainment in primary school could help to improve adolescent health. [ABSTRACT FROM AUTHOR]

Objectives: Exercise is reported to improve function for people with ankylosing spondylitis (AS) but it is not clear if this effect is causal or if patients with milder disease find it easier to exercise. This study examines the effect of exercise and motivation to exercise on function, while controlling for disease severity. Methods: Participants who were members of an existing AS cohort were asked about physical activity, motivation to exercise, function, and disease severity. Path analysis on STATA was used to examine the correlation between factors associated with function at time of exercise and with function after 3 months of follow-up. Results: The response rate to the questionnaire was 88% (326/371). Improvement in function was greatest for people with higher physical activity levels and those who were more motivated to exercise—this was especially the case for patients with the most severe disease activity. The effect of motivation to exercise not only had a direct effect on function, but also an indirect effect of improving activity levels thereby improving both current and future function. People with high intrinsic motivation (driven by pleasure) had the greatest benefit to activity and function. Conclusions: Exercise does improve function, especially for those with severe disease. In addition, motivation alone improves function as much as exercising itself. Therefore, interventions targeting motivation to exercise would have as much effect on improving function as interventions offering exercise opportunities. In addition, any intervention that both improves motivation and increases opportunities to exercise would have a 2-fold influence on function. [Copyright &y& Elsevier]

Objectives: Fatigue is an important symptom associated with ankylosing spondylitis (AS). This study examines patients'' perspectives and clinical associations of fatigue to help inform potential strategies to alleviate fatigue in AS. Methods: A mixed methods approach was taken to examine fatigue in a cohort of people with AS. Fatigue levels were evaluated from 3 consecutive monthly questionnaires. Open-ended questions on fatigue were analyzed using thematic analysis and logistic regression was used to examine quantitative data. In addition, fatigue levels were examined before and after treatment with anti-tumor necrosis factor (TNF) compared to nontreated controls. Results: Three hundred forty-eight of 385 participants completed a fatigue questionnaire. Fatigue was reported to have significant physical, social, and psychological effects. A third of the participants reported that there was nothing they could do to reduce their fatigue, whereas other participants reported that medication, exercise, and resting helped. The main factor associated with fatigue was pain [β-coefficient: 0.74 (95% CI: 0.66 to 0.81)], whereas depression was much less strongly associated. However, these factors only explained 40% of the variation in fatigue levels. Starting anti-TNF therapy reduced fatigue and pain levels compared to the period of time before taking anti-TNF [difference: 14.4 (95% CI: 5.3 to 23.5) on a scale of 0-100] and this reduction was not seen in controls over the same period. Conclusions: Fatigue is not strongly associated with anxiety, motivation, and depression; instead the factor most associated with fatigue is pain. This suggests that in addition to treatments to reduce disease activity, strategies for alleviating fatigue in AS should focus on pain management techniques and actively treating inflammation. [Copyright &y& Elsevier]

Objectives: To examine if people with ankylosing spondylitis (AS) are at higher risk of acute myocardial infarction (MI) or stroke compared to those without AS. Methods: Primary care records were linked with all hospital admissions and deaths caused by MI or stroke in Wales for the years 1999-2010. The linked data were then stratified by AS diagnosis and survival analysis was used to obtain the incidence rate of MI and separately cerebrovascular disease (CVD)/stroke. Cox regression was used to adjust for gender and age. Logistic regression was used to examine prevalence of diabetes, hypertension, or hyperlipidemia for those with AS compared to those without. Results: There were 1686 AS patients (75.9% male, average age 46.1 years) compared to 1,206,621 controls (48.9% male, average age 35.9 years). Age- and gender-adjusted hazard ratios for MI were 1.28 (95% CI: 0.93 to 1.74) P = 0.12, and for CVD/stroke 1.0 (95% CI: 0.73 to 1.39) P = 0.9, in AS compared to controls. The prevalence of diabetes and hypertension, but not hyperlipidemia/hypercholesterolemia, was higher in AS. Conclusions: There is no increase in the MI or CVD/stroke rates in patients with AS compared to those without AS, despite higher rates of hypertension, which may be related to nonsteroidal anti-inflammatory drug use. [ABSTRACT FROM AUTHOR]

Summary: Europe has one of the lowest rates of child mortality in the world. However, there are still large differences in death rates even among European Union (EU) member states. Examining changes in mortality rates across some European countries can help us understand how death rates might further be reduced. A review of mortality data obtained from the World Health Organisation for the EU member states between 1968 and 2002 shows that childhood mortality rates have currently declined at a rate of 1 per 100000 per year. Rates in eastern Europe are twice those of Scandinavia and most children die in the countries with moderate rates and a large population (i.e. Germany, Poland, Spain and UK). The highest rates are among the preschool age and among boys. The lowest rates are among girls and the 5–10 age group. Non-infectious/non-cancer disease and injury are the main reasons for death. However, deaths due to injury are more preventable and are falling at a faster rate than infectious disease and cancer. Dividing deaths into specific causes according to International Statistical Classification of Diseases and Related Health Problems, tenth revision codes shows that transport accidents, congenital malformation (i.e. heart malformations) and disorders of the nervous system (epilepsy, cerebral palsy) are currently the leading causes of death. Therefore, childhood mortality rates have declined greatly in Europe over the last 30 years. The countries with the higher levels of mortality are those that are still relatively poor (eastern Europe). Currently, in eastern Europe the main cause of childhood death is injury, while in western Europe it is non-infectious, non-cancer disease (epilepsy, congenital malformations). Traffic accidents are the main single cause of death in children in Europe as a whole. [Copyright &y& Elsevier]

Highlights: [•] Women who did not take up the HPV vaccination were less likely to attend for cervical screening. [•] HPV vaccinated women who attended cervical screening had the lowest proportion of cytological abnormalities detected. [•] Social deprivation was the main factor-affecting uptake of both HPV vaccination and cervical screening. [Copyright &y& Elsevier]

Introduction: Physical activity declines in adolescence, especially among those in deprived areas. Research suggests this may result from accessibility barriers (e.g., cost and locality). The Active Children Through Individual Vouchers Evaluation RCT aimed to improve the fitness and heart health of teenagers in Wales with the help of teenagers who co-produced the study.Study Design: This study was a mixed-method RCT.Setting/participants: Before data collection, which took place at baseline, 6 months, and 12 months for both arms, 7 schools were randomized by an external statistician (4 intervention schools, n=524; 3 control schools, n=385).Intervention: The Active Children Through Individual Vouchers Evaluation intervention included provision of activity vouchers (£20 per month), a peer mentoring scheme, and support worker engagement for 12 months between January and December 2017. Data analysis occurred February-April 2018.Main Outcome Measures: Data included measures of cardiovascular fitness, cardiovascular health (blood pressure and pulse wave analysis), motivation, and focus groups.Results: The intervention showed a trend to improve the distance ran (primary outcome) and was significant in improving the likelihood of intervention teenagers being fit (OR=1.21, 95% CI=1.07, 1.38, p=0.002). There was a reduction in teenagers classified as having high blood pressure (secondary outcome) in the intervention group (baseline, 5.3% [28/524]; 12 months, 2.7% [14/524]). Data on where teenagers used vouchers and evidence from focus groups showed that teenagers wanted to access more unstructured, informal, and social activities in their local areas.Conclusions: Active Children Through Individual Vouchers Evaluation identified methods that may have a positive impact on cardiovascular fitness, cardiovascular health, and perspectives of activity. Consulting with teenagers, empowering them, and providing more local opportunities for them to take part in activities that are fun, unstructured, and social could positively impact teenage physical activity.Trial Registration: ISRCTN, ISRCTN75594310. [ABSTRACT FROM AUTHOR]

Objectives Cost-effectiveness analyses of technologies for patients with ankylosing spondylitis frequently require estimates of health utilities as a function of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and the Bath Ankylosing Spondylitis Functional Index (BASFI). Methods Linear regression, bespoke mixture models, and generalized ordered probit models were used to model the EuroQol five-dimensional questionnaire as a function of BASDAI and BASFI. Data were drawn from a large UK cohort study (n = 516 with up to five observations) spanning the full range of disease severity. Results Linear regression was systematically biased. Three- and four-component mixture models and generalized probit models exhibit no such bias and improved fit to the data. The mean, median, mean error, and mean absolute error favored the mixture model approach. Root mean square error favored the generalized ordered probit model approach for the data as a whole. Model fit assessed using these same measures by disease severity quartiles tended to be best using the mixture models. The value of moving from good to poor health may differ substantially according to the chosen method. Simulated data from the mixture and probit models yield a very similar distribution to the original data set. Conclusions These results add to a body of evidence that the statistical model used to estimate health utilities matters. Linear models are not appropriate. The four-class bespoke mixture model approach provides the best performing method to estimate the EuroQol five-dimensional questionnaire values from BASDAI and BASFI. [ABSTRACT FROM AUTHOR]